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Douflé G, Dragoi L, Morales Castro D, Sato K, Donker DW, Aissaoui N, Fan E, Schaubroeck H, Price S, Fraser JF, Combes A. Head-to-toe bedside ultrasound for adult patients on extracorporeal membrane oxygenation. Intensive Care Med 2024; 50:632-645. [PMID: 38598123 DOI: 10.1007/s00134-024-07333-7] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Track Full Text] [Journal Information] [Subscribe] [Scholar Register] [Received: 11/10/2023] [Accepted: 01/20/2024] [Indexed: 04/11/2024]
Abstract
Bedside ultrasound represents a well-suited diagnostic and monitoring tool for patients on extracorporeal membrane oxygenation (ECMO) who may be too unstable for transport to other hospital areas for diagnostic tests. The role of ultrasound, however, starts even before ECMO initiation. Every patient considered for ECMO should have a thorough ultrasonographic assessment of cardiac and valvular function, as well as vascular anatomy without delaying ECMO cannulation. The role of pre-ECMO ultrasound is to confirm the indication for ECMO, identify clinical situations for which ECMO is not indicated, rule out contraindications, and inform the choice of ECMO configuration. During ECMO cannulation, the use of vascular and cardiac ultrasound reduces the risk of complications and ensures adequate cannula positioning. Ultrasound remains key for monitoring during ECMO support and troubleshooting ECMO complications. For instance, ultrasound is helpful in the assessment of drainage insufficiency, hemodynamic instability, biventricular function, persistent hypoxemia, and recirculation on venovenous (VV) ECMO. Lung ultrasound can be used to monitor signs of recovery on VV ECMO. Brain ultrasound provides valuable diagnostic and prognostic information on ECMO. Echocardiography is essential in the assessment of readiness for liberation from venoarterial (VA) ECMO. Lastly, post decannulation ultrasound mainly aims at identifying post decannulation thrombosis and vascular complications. This review will cover the role of head-to-toe ultrasound for the management of adult ECMO patients from decision to initiate ECMO to the post decannulation phase.
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Affiliation(s)
- Ghislaine Douflé
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada.
- Department of Anesthesia and Pain Management, Toronto General Hospital, 585 University Avenue, Toronto, ON, M5G 2N2, Canada.
| | - Laura Dragoi
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Diana Morales Castro
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Kei Sato
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Dirk W Donker
- Intensive Care Center, University Medical Center Utrecht (UMCU), Utrecht, The Netherlands
- Cardiovascular and Respiratory Physiology, TechMed Centre, University of Twente, Enschede, The Netherlands
| | - Nadia Aissaoui
- Service de Médecine intensive-réanimation, Hôpital Cochin, Assistance Publique-Hôpitaux de Paris (AP-HP), Université Paris Cité, Paris, France
| | - Eddy Fan
- Interdepartmental Division of Critical Care Medicine of the University of Toronto, Toronto, ON, Canada
| | - Hannah Schaubroeck
- Department of Intensive Care Medicine, Department of Internal Medicine and Pediatrics, Ghent University Hospital, Ghent University, Corneel Heymanslaan 10, 9000, Ghent, Belgium
| | - Susanna Price
- Departments of Cardiology and Intensive Care, Royal Brompton & Harefield NHS Foundation Trust, London, UK
- National Heart and Lung Institute, Imperial College London, London, UK
| | - John F Fraser
- Critical Care Research Group, The Prince Charles Hospital, Level 3 Clinical Sciences Building, Chermside, QLD, 4032, Australia
- Faculty of Medicine, University of Queensland, Brisbane, QLD, Australia
| | - Alain Combes
- Service de Médecine Intensive-Réanimation, Institut de Cardiologie, APHP Sorbonne Université, Hôpital Pitié Salpêtrière, Paris, France
- Institute of Cardiometabolism and Nutrition, Sorbonne Université, INSERM, UMRS_1166-ICAN, Paris, France
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Charbonneau F, Chahinian K, Bebawi E, Lavigueur O, Lévesque É, Lamarche Y, Serri K, Albert M, Noly PE, Cournoyer A, Cavayas YA. Parameters associated with successful weaning of veno-arterial extracorporeal membrane oxygenation: a systematic review. Crit Care 2022; 26:375. [PMID: 36471408 PMCID: PMC9724323 DOI: 10.1186/s13054-022-04249-w] [Citation(s) in RCA: 0] [Impact Index Per Article: 0] [Reference Citation Analysis] [Abstract] [Key Words] [MESH Headings] [Grants] [Track Full Text] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 09/30/2022] [Accepted: 11/19/2022] [Indexed: 12/12/2022] Open
Abstract
PURPOSE Veno-arterial (VA) extracorporeal membrane oxygenation (ECMO) can be used to restore organ perfusion in patients with cardiogenic shock until native heart recovery occurs. It may be challenging, however, to determine when patients can be weaned successfully from ECMO-surviving without requiring further mechanical support or heart transplant. We aimed to systematically review the medical literature to determine the biomarkers, hemodynamic and echocardiographic parameters associated with successful weaning of VA-ECMO in adults with cardiogenic shock and to present an evidence-based weaning algorithm incorporating key findings. METHOD We systematically searched PubMed, Embase, ProQuest, Google Scholars, Web of Science and the Grey literature for pertinent original research reports. We excluded studies limited to extracorporeal cardiopulmonary resuscitation (ECPR) as the neurological prognosis may significantly alter the decision-making process surrounding the device removal in this patient population. Studies with a mixed population of VA-ECMO for cardiogenic shock or cardiac arrest were included. We excluded studies limited to patients in which ECMO was only used as a bridge to VAD or heart transplant, as such patients are, by definition, never "successfully weaned." We used the Risk of Bias Assessment tool for Non-Randomized Studies. The study was registered on the International prospective register of systematic reviews (PROSPERO CRD42020178641). RESULTS We screened 14,578 records and included 47 that met our pre-specified criteria. Signs of lower initial severity of shock and myocardial injury, early recovery of systemic perfusion, left and right ventricular recovery, hemodynamic and echocardiographic stability during flow reduction trial and/or pump-controlled retrograde trial off predicted successful weaning. The most widely used parameter was the left ventricular outflow tract velocity time integral, an indicator of stroke volume. Most studies had a moderate or high risk of bias. Heterogeneity in methods, timing, and conditions of measurements precluded any meta-analysis. CONCLUSIONS In adult patients on VA-ECMO for cardiogenic shock, multiple biomarkers, hemodynamic and echocardiographic parameters may be used to track resolution of systemic hypoperfusion and myocardial recovery in order to identify patients that can be successfully weaned.
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Affiliation(s)
- Francis Charbonneau
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Karina Chahinian
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Emmanuel Bebawi
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Olivier Lavigueur
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
| | - Émilie Lévesque
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Yoan Lamarche
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Karim Serri
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Martin Albert
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Pierre-Emmanuel Noly
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada
| | - Alexis Cournoyer
- Department of Emergency Medicine, Hôpital du Sacré-Cœur de Montréal, Montreal, Canada
| | - Yiorgos Alexandros Cavayas
- Division of Critical Care, Department of Medicine, Hôpital du Sacré-Cœur de Montréal, 5400 Boulevard Gouin Ouest, Montreal, QC, H4J 1C5, Canada.
- Division of Critical Care, Department of Surgery, Montreal Heart Institute, Montreal, Canada.
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Mørk SR, Bøtker MT, Christensen S, Tang M, Terkelsen CJ. Survival and neurological outcome after out-of-hospital cardiac arrest treated with and without mechanical circulatory support. Resusc Plus 2022; 10:100230. [PMID: 35434669 PMCID: PMC9010695 DOI: 10.1016/j.resplu.2022.100230] [Citation(s) in RCA: 8] [Impact Index Per Article: 4.0] [Reference Citation Analysis] [Abstract] [Track Full Text] [Download PDF] [Figures] [Journal Information] [Subscribe] [Scholar Register] [Received: 02/01/2022] [Revised: 03/09/2022] [Accepted: 03/18/2022] [Indexed: 11/18/2022] Open
Abstract
Aim The aim of this study was to describe the survival and neurological outcome in patients with OHCA treated with and without mechanical circulatory support (MCS). Methods This was a retrospective observational cohort study on patients with OHCA admitted to Aarhus University Hospital, Denmark, between January 2015 and December 2019. Kaplan-Meier estimates were used to evaluate 30-day and 30–180-day survival. Cox regression analysis was used to assess the association between covariates and one-year mortality. Results Among 1,015 patients admitted, 698 achieved return of spontaneous circulation (ROSC) before admission, 101 patients with refractory OHCA received mechanical circulatory support (MCS) and the remaining 216 patients with refractory OHCA did not receive MCS treatment. Survival to hospital discharge was 47% (478/1015). Good neurological outcome defined as Cerebral Performance Categories 1–2 were seen among 92% (438/478) of the patients discharged from hospital. Median low-flow was 15 [8–22] minutes in the ROSC group and 105 [94–123] minutes in the MCS group. Mortality rates were high within the first 30 days, however; 30–180-day survival in patients discharged remained constant over time in both patients with ROSC on admission and patients admitted with MCS. Advanced age > 70 years (hazard ratio (HR) 1.98, 95% confidence interval (CI) 1.11–3.49), pulseless electrical activity (HR 2.39, 95% CI 1.25–4.60) and asystole HR 2.70, 95% CI 1.25–5.95) as initial rhythms were associated with one-year mortality in patients with ROSC. Conclusions Short-term survival rates were high among patients with ROSC and patients receiving MCS. Among patients who survived to day 30, landmark analyses showed comparable 180-day survival in the two groups despite long low-flow times in the MCS group. Advanced age and initial non-shockable rhythms were independent predictors of one-year mortality in patients with ROSC on admission.
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Affiliation(s)
- Sivagowry Rasalingam Mørk
- Department of Cardiology, Aarhus University Hospital, Denmark
- Aarhus University, Aarhus, Denmark
- Corresponding author at: Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, DK-8200 Aarhus N, Denmark.
| | - Morten Thingemann Bøtker
- Aarhus University, Aarhus, Denmark
- Research and Development, Prehospital Emergency Medical Services, Central Denmark Region, Denmark
| | - Steffen Christensen
- Aarhus University, Aarhus, Denmark
- Department of Anesthesiology and Intensive Care, Aarhus University Hospital, Denmark
| | - Mariann Tang
- Aarhus University, Aarhus, Denmark
- Department of Thoracic and Vascular Surgery, Aarhus University Hospital, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Denmark
- Aarhus University, Aarhus, Denmark
- The Danish Heart Foundation, Denmark
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Mørk SR, Stengaard C, Linde L, Møller JE, Jensen LO, Schmidt H, Riber LP, Andreasen JB, Thomassen SA, Laugesen H, Freeman PM, Christensen S, Greisen JR, Tang M, Møller-Sørensen PH, Holmvang L, Gregers E, Kjaergaard J, Hassager C, Eiskjær H, Terkelsen CJ. Mechanical circulatory support for refractory out-of-hospital cardiac arrest: a Danish nationwide multicenter study. CRITICAL CARE : THE OFFICIAL JOURNAL OF THE CRITICAL CARE FORUM 2021; 25:174. [PMID: 34022934 PMCID: PMC8141159 DOI: 10.1186/s13054-021-03606-5] [Citation(s) in RCA: 33] [Impact Index Per Article: 11.0] [Reference Citation Analysis] [Abstract] [Key Words] [Track Full Text] [Download PDF] [Figures] [Subscribe] [Scholar Register] [Received: 03/23/2021] [Accepted: 05/14/2021] [Indexed: 12/16/2022]
Abstract
Background Mechanical circulatory support (MCS) with either extracorporeal membrane oxygenation or Impella has shown potential as a salvage therapy for patients with refractory out-of-hospital cardiac arrest (OHCA). The objective of this study was to describe the gradual implementation, survival and adherence to the national consensus with respect to use of MCS for OHCA in Denmark, and to identify factors associated with outcome. Methods This retrospective, observational cohort study included patients receiving MCS for OHCA at all tertiary cardiac arrest centers (n = 4) in Denmark between July 2011 and December 2020. Logistic regression and Kaplan–Meier survival analysis were used to determine association with outcome. Outcome was presented as survival to hospital discharge with good neurological outcome, 30-day survival and predictors of 30-day mortality. Results A total of 259 patients were included in the study. Thirty-day survival was 26%. Sixty-five (25%) survived to hospital discharge and a good neurological outcome (Glasgow–Pittsburgh Cerebral Performance Categories 1–2) was observed in 94% of these patients. Strict adherence to the national consensus showed a 30-day survival rate of 30% compared with 22% in patients violating one or more criteria. Adding criteria to the national consensus such as signs of life during cardiopulmonary resuscitation (CPR), pre-hospital low-flow < 100 min, pH > 6.8 and lactate < 15 mmol/L increased the survival rate to 48%, but would exclude 58% of the survivors from the current cohort. Logistic regression identified asystole (RR 1.36, 95% CI 1.18–1.57), pulseless electrical activity (RR 1.20, 95% CI 1.03–1.41), initial pH < 6.8 (RR 1.28, 95% CI 1.12–1.46) and lactate levels > 15 mmol/L (RR 1.16, 95% CI 1.16–1.53) as factors associated with increased risk of 30-day mortality. Patients presenting signs of life during CPR had reduced risk of 30-day mortality (RR 0.63, 95% CI 0.52–0.76). Conclusions A high survival rate with a good neurological outcome was observed in this Danish population of patients treated with MCS for OHCA. Stringent patient selection for MCS may produce higher survival rates but potentially withholds life-saving treatment in a significant proportion of survivors. Supplementary Information The online version contains supplementary material available at 10.1186/s13054-021-03606-5.
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Affiliation(s)
- Sivagowry Rasalingam Mørk
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.
| | - Carsten Stengaard
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Louise Linde
- Department of Cardiology, Odense University Hospital, Odense, Denmark
| | | | | | - Henrik Schmidt
- Department of Anaesthesiology and Intensive Care, Odense University Hospital, Odense, Denmark
| | - Lars Peter Riber
- Department of Thoracic and Vascular Surgery, Odense University Hospital, Odense, Denmark
| | - Jo Bønding Andreasen
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Sisse Anette Thomassen
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | - Helle Laugesen
- Department of Anaesthesiology and Intensive Care, Aalborg University Hospital, Aalborg, Denmark
| | | | - Steffen Christensen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Jacob Raben Greisen
- Department of Anaesthesiology and Intensive Care, Aarhus University Hospital, Aarhus, Denmark
| | - Mariann Tang
- Department of Thoracic and Vascular Surgery, Aarhus University Hospital, Aarhus, Denmark
| | | | - Lene Holmvang
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Emilie Gregers
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Jesper Kjaergaard
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Christian Hassager
- Department of Cardiology, Copenhagen University Hospital, Copenhagen, Denmark
| | - Hans Eiskjær
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark
| | - Christian Juhl Terkelsen
- Department of Cardiology, Aarhus University Hospital, Palle Juul-Jensens Boulevard 99, 8200, Aarhus N, Denmark.,The Danish Heart Foundation, Copenhagen, Denmark
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